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“IAPT The Myth and The Reality” Scuppered By Two BABCP Presidents

last week I received an extraordinary e-mail, not from the editor of CBT Today, to whom I had submitted the aforementioned article, but from the President of the British Association of Behavioural and Cognitive Therapies (BABCP), Paul Salkovskis and the President-Elect, Andrew Beck declining my article. I protested that this was an infringement of editorial freedom. Further there was a conflict of interest (COI)  because my article was written in response to one by Paul extolling the virtues of IAPT.  This issue of editorial interference was highlighted a year ago when the Editor of CBT Today and Paul declared that there would be no further discussion of IAPT following a piece by Jason Roscoe ‘Has IAPT Become A Bit Like Frankenstein’s Monster?’  and a rebuttal by David Clark. In a response Andrew Beck has now agreed to take the issues of editorial freedom and conflict of interests to the BABCP Board. But this also happened 5 years ago under the Chris William’s Presidency, to no effect!

 the then President sent me an e-mail on December 16th 2015 which read:

‘I don’t want to pre-empt what the Board might decide – as I am only one member of that board – however I am the Board member on the journal committee and am personally very keen we have clear COI statements. My own view is that probably most of these authors doing research in IAPT and also employed in such services aren’t even considering this as an issue as they don’t see themselves as being influenced by IAPT centrally – however that isn’t the point. What matters is perceived conflict and it’s quite clear that you and at least some others have a concern. I would be very happy on a personal basis to advocate we remind authors and associate editors of COI more in such cases and will do so in person or by email at the next journal committee meeting and provide you with feedback as to what happens then’ 

The IAPT Skulduggery Has Continued 

In answer to Jason Roscoe’s question ‘Has IAPT Become A Frankenstein’s Monster? ” –  I  can answer in the affirmative – the latest issue of the British Journal of Clinical  Psychology DOI:10.1111/bjc.12259 contains a supposed 10 year review of IAPT data. The authors all declare no conflict of interest, but the corresponding author for the study is Stephen Kellet who is an IAPT Programme Director! 

Other Examples of IAPT’s ‘Failure To Declare’

  1. In an article that mirrors the Kellett et al paper,  by the prime lead in IAPT David Clark, in the Lancet (2018) there was no declaration of a conflict of interest. Ironically the title has in it the word ‘Transparency’!
  2.  In a paper by Boyd, Baker and Reilly (2019) interventions it is written ‘The authors have declared that no competing interests exist’ , but the lead author presenting at a Conference in Amsterdam in May 2016 is described thus: ‘Lisa Boyd, IAPT service, Tees Esk and Wear Valley Mental Health Trust, UK Impact of a Progressive Stepped Care Approach in an Improving Access to Psychological Therapies Service: An Observational Study’
  3. In the paper ‘How durable is the effect of low intensity CBT for depression and anxiety? Remission and relapse in a longitudinal cohort study’ was written by Ali et al (2017) , Behaviour Research and Therapy 94 1-8. the authors declared no conflict of interest but the corresponding author was Chair of the Northern IAPT Practice Research Network

Enough is enough the very credibility of BABCP is at stake and as for IAPT! But I guess this blog would be found ‘unsuitable’ for CBT Today!

Ethical standards have become a joke

Dr Mike Scott



IAPT’s Flagship The PHQ-9 Hits An Iceberg

the PHQ-9, IAPT’s sole determinant of depression. identifies two and a half times as many people as depressed compared to the ‘gold standard’ diagnostic interview the SCID,  see Levis et al (2020) in this months issue of the Journal of Clinical Epidemiology .  This makes for garbage assessment (GA), the same measure is used by the service to measure outcome, garbage outcome (GO).  In the computer world  the mnemonic GIGO is used to denote, that if you put garbage into a computer you get garbage out. For mental health clinicians there should be a new addition to the lectionary GAGO. But who is answerable for flagship IAPT (Improving Access to Psychological Treatments) racing towards the iceberg? who is going to pick up the survivors? 

Levis et al (2020) comment that the PHQ-9 results are rather like a positive mammogram test for breast cancer, the result would give a grossly inflated view of the prevalence of breast cancer. They argue that that the PHQ-9 results only have any validity in the context of a standardised diagnostic interview. IAPT has never used such an interview, its’ claim for a 50% recovery rate is outrageous.

Interestingly the Journal paper found that there was no cut off score on the  PHQ-9 that meaningfully differentiated those in need of treatment from those who did not. Yet IAPT uses the cut off score of greater than 10 to denote a ‘case’, with an implicit treatment requirement.  Those scoring greater than 10 could be suffering from almost anything, adjustment disorder, a specific phobia, binge eating disorder etc or simply cheesed off with their debility following say the development of sepsis after an operation and ongoing impairment.

Ironically the fault with the PHQ-9 may lie in its’ origins. It was validated not against an acknowledged reference standard, such as the SCID, but against the PRIME MD, Kroenke et al (2001) J GEN INTERN MED 16:606-613 which asks in interview form exactly the same questions as on the PHQ-9. This contravenes one of the STARD, [Cohen et al (2016) doi:10.1136/bmjopen-2016- 012799 ] requirements to judge the diagnostic accuracy of a test, in that the reference standard must contain much more detailed information (e.g about levels of functional impairment) than that contained in the index test.   

The development of the PHQ-9 and the PRIME-MD were both funded by Pfizer Pharmaceuticals. The over identification of cases of depression is clearly in the interests of a pharmaceutical company. Clinicians also welcome with open arms anything that appears to reduce the assessment burden. Their employers, such as IAPT can rejoice that this surrogate  for reliable diagnosis, shows a reducing score with time [regression to the mean – Gilbody et al. (2015) looked at how GP patients with a PHQ-9 score of greater than 10 fare with usual treatment, over a four-month period; their mean PHQ-9 score reduced from 16 to 9],  which they can publicly misattribute to the benefits of therapy, and can convince the more naive of their clinicians that they are making a real world difference. IAPT continues in its’ bubble, shared with the supposed UK lead organisation for cognitive behaviour therapy, the British Association for Cognitive and Behaviour Therapy (BABCP).

Dr Mike Scott



This Misuse Of IAPT Data Will Justify Cramming Clients Into Group Therapy

a just published study  of IAPT clients by Fanous and Daniels (2020) doi:10.1017/S1754470X20000045 apparently reveals that group CBT for generalised anxiety disorder is as good as individual cbt. But its’ assessment process was like no other in the randomised controlled trials of CBT for GAD. Making comparison between this study  and meta analysis of GAD outcome studies by Zhu et al  (2014) impossible.  Specifically:

  1. Entry into the study was not determined by any of the standardised diagnostic interviews used in other controlled trials of CBT for GAD. Thus there can be no certainty that the population studied is the same as that in other rcts, i.e that they were suffering from GAD as the primary disorder. 
  2. The interview that was used to determine entry was not reused post treatment. Thus preventing a determination of the proportion of clients no longer suffering from GAD at the end.
  3. It is claimed that those entering the study were assessed according to the ICD 10 criteria for generalised anxiety disorder. But  in the ICD 10, GAD is a diagnosis of exclusion, it requires that a wide range of disorders to have first been excluded including depressive disorder, panic disorder and a specific phobia. Such differential diagnosis requires a very extensive clinical interview, see Clinical Interviewing Sommers- Flanagan 2016. There is no evidence that such an interview took place and it is unlikely to have done so as IAPT’s mantra ( see IAPT Manual) is that it doesn’t make diagnoses. What has happened is that the gatekeepers to the study have de facto used the GAD7 (which is based on the DSM criteria) for entry into the study and as the major metric of recovery.  But DSM-5, p19 [American Psychiatric (2013)]  explicitly counsels against the use of symptom checklists thus: ‘ it is not sufficient to simply check off the symptoms in the diagnostic criteria to make a mental disorder diagnosis’.
  4. The primary outcome measure used was the GAD7, though popular in IAPT this measure was not used in any of the 12 rcts of CBT for GAD  considered by Zhu et al (2014) Indeed Fanous and Daniels (2020) make no reference to this meta analysis.
  5. There was no independent blind assessment of outcome in the Fanous and Daniels (2020) study. Half the studies in the Zhu et al (2014) meta analysis had blind assessors and their findings were not as flattering as the self report measures.
  6. The authors failed to consider whether the found changes could have occurred in any case with the passage of time, as clients typically present initially at their worst. The effect sizes in the Fanous and Daniels (2020) study were 0.90 in group CBT and 0.94 in individual CBT, i.e the average client treated improved by less than 1 standard deviation. This should have been set in the context of  an 0.38 within subjects effect size found in GAD patients on a waiting list for CBT, see Robinson et al (2010)  and effect sizes of 1.73 and 1.55 in the comparison different modes of internet delivered CBT treatment.
  7. The authors use a score of below 10 at the end of treatment as indicating recovery, but this is not the metric used in any other study.  Yet using this, in true IAPT style, they claim a 53% recovery in individual CBT and a 41% recovery in group cbt. It is extremely doubtful that one half of the IAPT clients would have regarded themselves as back to their usual self after treatment.
  8. The GAD7 refers only to functioning in the last 2 weeks, whereas the DSM criteria refer to functioning over the last 6 months, recognising that anxiety symptoms do wax and wane. Thus to be regarded as in remission from GAD requires a significant period [at least 8 weeks as operationalised by Bruce et al (2005)] without the disorder. There is nothing in this IAPT study to suggest anyone was remitted in any meaningful way. Nonetheless the authors of the study promote the virtues of allegedly group cbt  over individual cbt.
  9. There may be a case for preferring group cbt over individual cbt, see Simply Effective Group Cognitive Behaviour Therapy [Scott (2011) London: Routledge], but this study does nothing to advance the case.  It is likely to result in the cramming in of a wide range of IAPT clients into ‘group cbt’ for ‘GAD’. A meta analysis of CBT for anxiety disorders and PTSD by Carpenter et al (2018) http://DOI: 10.1002/da.22728 found that sufficient data was only available for social anxiety disorder and PTSD  and for both disorders individual cbt was superior to group cbt.
  10. The Fanous and Daniels (2020) study had a dropout rate of about a third in each arm, making its’ intention to treat statistical procedure questionable, usually such a procedure is only used when the dropout rate is less than 20%.
  11. The study is retrospective, so it is not detailed how many people declined group CBT, an all too familiar occurrence in the author’s experience see Scott (2011). This gives a misleading impression of the acceptability of group cbt and minimises the complexity of selling it.
  12. In the Fanous and Daniels (2020) study there were no fidelity checks on the High Intensity clinicians to gauge whether they were tackling GAD treatment targets with matching treatment strategies.   This reflects the more general problem in IAPT, the espousal of NICE recommended treatments together with a paucity of evidence as to actual delivery at the coalface.


Dr Mike Scott

Chair BABCP Group CBT Special Interest Group

Outcome In Talking Therapies – Calling a Spade a Spade

when did you last hear of a therapist asking a client ‘do those close to you think you are back to your old self now?’, ‘do you think you are back to your old self? ‘how long do you feel that you have been back to your normal?  Yet these questions reflect the implicit dominant concerns of clients. It is at a minimum, neglect not to ask such questions and we may come to see this failure at some future point as abuse.

But Improving Access to Psychological Therapies (IAPT) therapists typically concentrate on whether there has been an improvement of 6 points on the PHQ9, with no attention to how long the improvement has persisted and they are then ejected from treatment.  Client’s are not asked whether the said change on the psychometric test constitutes a minimally clinically significant improvement in their condition.  Nor is there any evidence that the chosen psychometric test is pertinent to the primary disorder for which they were seeking treatment. The typically administered PHQ9 and GAD7 are highly correlated and may not even represent separate constructs i.e depression and generalised anxiety, and by themselves are dubious vectors for directing treatment. 

It is a sleight of hand to claim that the 6 point improvement on the PHQ9 or indeed scoring below 10 at post treatment say anything meaningful about the client’s real world if the test is used outside the context of a standardised diagnostic interview that identified depression as the primary disorder. Using the psychometric tests out of such contexts has more to do with income than outcome. For the unwary such changes seem ‘significant’ but the same change is observed in clients followed up without psychological therapy [see Gilbody (2015)]. Unfortunately it has proven all to easy to dupe Public Health England and Clinical Commissioning Groups. At present it seems it is too embarrassing for them to admit they have allowed themselves to be hoodwinked for years.


Dr Mike Scott

IAPT’s Modus Operandi: ‘squeeze the client into the briefest cbt, then eject’

and repeat the mantra that it is ‘world beating’ [ see Thrive by Layard and Clark (2014) and Can We Be Happier? Layard (2020)]. For Mariella her 7 IAPT (Improving Access to Psychological Therapies) sessions were a                     re-traumatisation of the abuse she had suffered in childhood. Four years after her IAPT treatment she was still suffering from low mood and likely chronic fatigue syndrome. The letter from the IAPT therapist said that she had responded to treatment because there had been a 6 point improvement on her PHQ9 and a 2 point improvement on the GAD7 and was therefore being discharged. Mariella refused to countenance a return to IAPT because she regarded it as having been a waste of time. IAPT specialises in putting square pegs in round holes:

Mariella’s maltreatment highlights several important issues:

  1. IAPT Gives Clients No Meaningful Choice At Either Entry or Exit. Mariella’s first face to face contact with the IAPT service was at a group meeting were she was invited to consider which of the services available might be most suitable for her. As she had spent years trying to discover what was really wrong with her she simply did not know what was appropriate for her.  She wondered whether her mood just changed like a bipolar relative. Mariella was convinced she had some underlying rheumatological disorder despite repeated negative testing. She was depressed that a few years ago she had been an exceptionally fit person and now it was total change. Mariella had no say in her discharge from treatment, her understanding was that she had had the allotted number of sessions. No follow up was arranged.
  2. IAPT Doesn’t Ask If Treatment Has Returned You To Your Old Self Mariella was never asked whether she was back to anything like her old self following treatment. The therapist simply pressed the eject button  after the predetermined number of sessions. There was no follow up to see whether improvement was enduring and whether treatment could be regarded as having made a real world difference.
  3. IAPTs Fixation on the PHQ9/GAD7 Mariella’s  score improved by 6 points on the PHQ9 during her IAPT treatment, this is held to be a ‘response’ by the service. This is to over interpret a test result. Such a change can occur with the passage of time e.g Gilbody et al (2015) particularly as people initially present at their worst. Further the test is administered without a reference standard, it was unknown whether Mariella’s primary disorder was depression, PTSD or CFS. No ‘gold standard’ assessment such SCID interview was conducted, making it impossible to a) gauge whether the selected test was actually tapping the primary disorder b) assess for comorbidity in Mariella’s case.  Yet comorbidity has treatment implications. 
  4. IAPT Not Only Fails To Identify Recognised Disorders But Also Fails To Recognise Personality Disorders In 2015 Goddard et al   used a personality disorder screen the SAPAS to gauge  whether it predicted outcome, it did But it has since taken no steps to help therapists reliably recognise the presence of a personality disorder. Given Mariella’s history it is not at all impossible that this was a factor in her being refractory to treatment.
  5. IAPTS Failure To Access GP Records Means That Important Information Is Missed The records revealed that despite the NICE approved graded exercise Mariella, would spend days of exhaustion after such exercise suggesting that something in the CFS domain is occurring. IAPT totally ignored this dimension. 
  6. IAPTs’ Usage of the PHQ9/GAD7 Has No Predictive/Prescriptive Value It is of no more value than Physiognamy in bygone centuries were it was thought that from a photograph of a person one could infer character traits.
  7. IAPT Repeats The Mantra That It Is ‘World Beating” But there is no evidence that it is any better than a) the passage of time b) previous ways of organising psychological therapy. See forthcoming blog ‘No Added Value’. IAPT should try repeating this mantra to Mariella. 

Mariella is not the exception.  IAPT spectacularly fails its’ clients, operating in some parallel universe, unfortunately hooked up to the power holders.  When will they ever learn?


  Dr Mike Scott



Testing For Mental Health Is A Token Gesture Compared to Testing For The Corona Virus

Nobody doubts that testing for the the Corona virus is a necessary part of the treatment planning for those with a fever and persistent cough. However the test alone is not judged sufficient, it has to be complemented by other clues such as the result of X-rays, a CT scan, and consideration of whole range of Covid-19 symptoms before the clinician makes a judgement on diagnosis. This contrasts sorely with the position in routine mental health services where in the Improving Access to Psychological Therapies (IAPT) service the sole arbiter of treatment decision making and judgement of outcome is the PHQ9/GAD7, accompanied by an unbridled clinical judgement. Yet the authors of the PHQ9 [Kroenke et al (2001 )] and GAD7 [Spitzer et al (2006)] insisted that the tests results needed to be interpreted in the context of a diagnostic interview. 

The completion of the PHQ9/GAD7 is mandated by the IAPT hierarchy, but clinicians have little or no interest in the results except that they may be disciplined if there is a pattern of non-recovery on these measures. IAPT Psychological Wellbeing Practitioners were asked to identify potential clients with GAD ( a score of 10 or more on the GAD7 ) for a study Kalpakidou et al (2019)  comparing the efficacy of CBT (delivered by high intensity therapists) to medication. But they put too few clients (only 12% of those potentially eligible) forward that the trial was cancelled. The take home message appears to be that for clinical purposes PWPS don’t take PHQ9/GAD7 measures seriously and operate on the basis of their own clinical judgement e.g whether a client’s stress is just a  natural reaction to a difficult situation or whether simple psychological first aid is judged sufficient to address difficulties. There appears to be little believe in the importance of stepping up clients and indeed only 10% of clients are stepped up. 

The judgement of PWP’s ( who provide over 70% of IAPT contacts) will likely be influenced by their training, the focus of which is on goal setting and tackling the most important problem see Richards and Whyte (2011) Reach Out 3rd Edition. But PWP’s are painfully unaware that such interviews have no more reliability that the standard open ended psychiatric interview with at most a 1 in 2 chance that different assessors seeing the same interview would agree  on the way forward [see Spitzer RL, Fleiss JL. A re-analysis of the reliability of psychiatric diagnosis. Br J Psychiatry 1974;125(0):341–7]. Essentially judgements are idiosyncratic unless a standardised semi-structured interview such as the SCID, DIAMOND or MINI is included in the assessment. Without such reliable assessments PWPs are operating outside the sphere of evidence based interventions.

Spitzer RL, Kroenke K, Williams JBW, Löwe B. A brief measure for assessing generalized anxiety disorder: the GAD-7. Arch Intern Med 2006;166:1092-1097.

Kroenke K, Spitzer RL, Williams JBW. The PHQ-9: Validity of a brief depression severity measure. J Gen Intern Med 2001;16:606-613.

Dr Mike Scott



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